Integrated Community Services Improvement Plan
Argyll and Bute Council · 27 November 2024
Back to Argyll and Bute HSCP Integration Joint Board (IJB) — 27 November 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 Meeting: Integration Joint Board (IJB). Date of Meeting: 27 November 2024 Title of Report: Integrated Community Services Improvement Plan Presented by: Caroline Cherry and Karl McLeish The IJB is asked to: ▪ Note the strategic national context around unscheduled care ▪ Note developments around sustainable integrated community services 1. EXECUTIVE SUMMARY The purpose of this report is to provide an overview of our system wide health and community care improvement plan, in the context of both national strategic asks and our older adult strategy, focusing on sustainable integrated community services. It should be interpreted in the context of The First Minister’s National Mission to reduce people in delay in hospital ahead of winter and to articulate our current activity and focus in relation to Urgent and Unscheduled Care and wider system pressure, with a particular focus on our plan to focus on improved and sustainable Integrated Community Services as a whole. 2. RECOMMENDATIONS The IJB is asked to note the contents for the report, by way of information and assurance, and offer any questions or feedback as appropriate. 3. DETAIL OF REPORT People delayed in hospital remain a national concern, and the national Collaborative Response and Assurance Group (CRAG) has been implemented to improve performance by way of a collaborative approach, across Scotland. The Group is proactively seeking assurance that all Health Boards reach compliance the national maximum level of delayed discharges of 34.6 per 100,000 adults. The specific ask was to scope: ‘the action and support that would be required within local areas to remove barriers to progress on achieving a material and sustained reduction in the number of people delayed in transfers of care from hospital. This is with a view to feeding back to the CRAG, recognising that we need to understand the local challenges and opportunities in order to best represent and support the needs of Local Government and, ultimately, the communities we serve.’ Besides CRAG, the Centre for Sustainable Delivery (CfSD) has also been commissioned to drive forwards collaborative system change, at national level, and has specified target areas/trajectories for improvement for each health Board. These are discussed within the main body of the paper at section 3.
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2 The collective asks of both CRAG and the CfSD is for partnerships to agree an integrated plan for improving system performance in a sustainable way. Although there is a primary focus on discharge without delay (as defined within the First Minister’s mission to improve delayed discharge) Argyll and Bute HSCP take the view that improvement around delayed discharge performance, and system resilience more generally, should be positioned as a key priority and objective within our integrated approach to improvement planning across all community services – working towards an integrated, sustainable operating model. The integrated plan is required to deliver against defined objectives in response to both regional and national prioritises/systems drivers for improvement. The plan is intended to approach improvement at two levels: 1. Service Improvement – rethinking our approach to services that we already deliver. This includes a focus on ensuring that there are clear service specification, standard operating procedures, access and quality standards. We are also committed to ensuring that the ethos of integration, both within areas and between teams, is operationalised in a way that supports true Multi- Disciplinary Working (MDT) and uses resource wisely. 2. Service redesign and transformation – working collaboratively to offer innovative service (re)design which results in implementation of service models. This is intended to offer strategically led additionality of resource which not only complements/improves system working and function, but also supports sustainable transformation. There are key national, strategic priorities which shape the direction of travel within both approaches detailed above. These are detailed within the strategic priorities as defined by the Centre for Sustainable Delivery (CfSD). • Maximise Capacity - Building capacity and capability across our region. This includes optimising and maximising the overall capacity to improve access. • Reduce Unnecessary Demand - Ensuring that we offer services by the right team at the right time. This avoids waste and enables rapid access to treatment to those who need it most. It is based around the principle of ensuring senior decision making at earlier points in the pathway, and the development of effective pathways which make best use of all capacity available, in line with assessed need and system priorities. • Harness Innovation - Harnessing technological/digital innovations to address some of the most complex challenges across our area to provide and improve access to services, reduce unnecessary service burden and promote independence. • Enhance staff capability and capacity - Identifying and maximising opportunities for staff upskilling and supporting generalist practice models. This includes taking into account the demands of the changing health and care environment and new ways of working. • Form and Continually Develop Strategic Partnerships - Developing partnerships with a range of skilled organisations to deliver transformation across a range of areas and disciplines. This includes working with national colleagues and collaborative, as well as working with primary and secondary care, Third Sector, Public Health digital health to deliver sustainable models of care. Context and Background for Our Community Plan
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3 In response to significant system pressure, and acknowledging the forthcoming seasonal impacts of winter, this report outlines the Argyll and Bute HSCPs system-wide Integrated Community Services Improvement Plan. The plan summarises the valuable feedback we have thus far received from engagement sessions, concerning current progress and priority actions required, including: • The significant challenges that Health and Social Care Partnerships faces, both in terms of finance, resources and population-based challenges. • The good practice that is already taking place across local areas to address these challenges and to continuously improve services and outcomes and, • The actions that were felt are needed at a regional and national level to facilitate a sustained and meaningful reduction in the levels of delay and improvement to flow overall. The plan is intended to encompass and engage colleagues and services, across all care groups, to co-produce, develop and deliver a consistent and integrated approach to integrated community service delivery – the impact of the plan is intended to deliver on short term priorities (immediate reduction of pressures and improvement of flow) as well as and longer-term objectives (sustainable reduction and timely prevention/management of delayed discharges). Given both Scottish Government and the Partnership’s priority to expedite hospital discharge, this work has traditionally tended to focus on hospital-based populations. However, it is equally important to ensure that we are prepared to prevent hospital admission, provide alternatives to acute care and promote independence at an early stage to reduce pressures/reliance on formal services within our communities. Our approach is therefore ‘whole system’, repositioning pressures such as delayed discharge as a symptom of the issues with flow rather than the cause. To that end, our joint work to date on the development of our Older Adult Strategy has involved a mapping of our whole system flow to understand where the opportunities for strategic improvement and changes are located. While further work is required on our data to definitively evidence the case for change, the available benchmarking data suggests that a number key performance indicators (i.e. numbers of people being admitted to hospital (emergency), length of stay in hospital, numbers and length of stay in delay) highlight that our figures are higher than would be expected, and that alternative models of care are needed. Due to the cross-cutting nature of this work, it is acknowledged that many of the priority areas detailed within our plan will require a continued management focus through a number existing work-streams. Overall progress across the integrated plan will be monitored using the Integrated Community Services Improvement Plan Tracker and meeting structure. This will be maintained by the Programme Manager for Urgent and Unscheduled Care. The governance and decision making for the integrated plan will be via defined subgroups and initially and will be reportable to the Community Standards Working Group. Our Overarching Strategic Vision In line with the Joint Strategic Plan for Argyll and Bute, the overarching aim is that people in ‘’Argyll and Bute will live longer, healthier, independent lives’’. In
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4 achieving this aim for population, our strategic focus is on transformation of services which both improves flow and maximises resources, but also support our vision to promoting independence and wellbeing. In order to achieve this strategic vision, a number of key areas of focus have been developed, including: Focus on Place and Wellbeing – Place Based Care with Quality Standards: • To build thriving communities by engaging, local communities, staff, and system partners to provide services which can deliver personalised care – the right care, by the right person, in the right place, at the right time. • To communicate in a clear, open and transparent way. • To focus on place-based needs to ensure that older adults are enabled to live well at home, or in a homely setting, while maximising independence and quality of life. • To maximise opportunities to provide safe, sustainable, and appropriate approaches to care home and housing provision. • To prioritise Community Wealth Building. • To deliver strategic, needs based, estates development plan – with a key focus on Care Homes and Housing (both current and future need). Focus on Preventative and Proactive Care Models: • To work with our partners in the third and independent sector to deliver services which are collaborative and anticipatory or future demands (for example day supports). • To actively promote opportunities and knowledge in our local communities, for staff and partners, which support early intervention, supported self- management and give individuals confidence to look after their health, to the best of their abilities out with the care of statutory services/resources. • To focus on preventative services, including a shift to greater uses of digital technology using Telecare and Telehealth - enabling increased access, reduced hospital visits and avoiding unnecessary admission. Focus on Planned Care Services – Service Improvement and Redesign: • To support people to develop and maintain the knowledge to manage their own health conditions, make positive choices, and lead healthier lives. • To develop services with personalised care, patient need and values at their core – clear service specification is a key essential. • To review access, capacity and flow models to reduce delays and improve timely access to services for those who need them. • To continue to work towards integrated services/MDT approaches, so that we are better able to get it right, the first time. • To continue to develop our specialised pathways, such as dementia and end of life care, so that patients can receive their care in the right place, at the right time. Unscheduled Care – Service Review and Redesign with a focus on MDT: • To proactively work to redesign urgent care, so that avoidable admissions are avoided and days spent in hospital are reduced. • To increase the services, we are able to offer within community teams, so that services which would traditionally require a specialist/hospital setting can be delivered at home.
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5 • To improve quality and processes around discharge pathways, to reduce discharge without delay and support people to come home more quickly. • To focus on anticipatory care planning so that we have robust plans in place and avoid any breakdown in care planning and/or delivery. • To increase accessibility using Technology and Digitalised care. Transformation and Sustainability • To ensure that our financial viability is considered in any transformation and development work. • To champion collaboration and engagement for and improvement, enabling our services to be inclusive, responsive and innovative. • To manage resources effectively to increase the quality of our services and provide them to those individuals and communities most at need. • To continue developing of an ambitious, effective, and ethical Partnership, with quality of care at the core. • To focus on recruitment: attracting skilled workers, continued commitment to colleague development and retention of skills. Plan, attract, train, value, nurture The table below shows the August position against the measures which have been submitted to Scottish Government as part of the Urgent and Unscheduled Care funding submission for 24-25. Additional measures include the Emergency Department 4 hours performance and number of breaches over 12 hours. These measures are based on the improvement areas identified by the Centre for Sustainable Delivery (CfSD) for NHS Highland. Baselines are set as March 2024, except the delayed discharge figures which are based on patient totals on Monday 3 June 2024. Integrated Community Services – Key Focus Points for Transformation and/or Service Development The key actions for this programme of work are:
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6 • Redefinition of Single Point of Contact (SPoC) Access - establishing a multidisciplinary, single point of access across areas based on a collective, agreed standard operating structure/guideline and governance structure. This is an essential area for review and transformation to ensure equity of access, and a consistent, rigorous approach to identifying patients’ needs and matching this with the optimal pathway without delay. • Redesign of Assessment and Care Management Frameworks, including Care Reviews: Developing a clear and standardised Process for the management of both community services (escalation and routine) and referrals to support community referral and hospital discharge. This will include a comprehensive review of referral pathways with a clear focus on expectations around timescales, MDT arrangements and roles and responsibilities. There will also be a clear focus on review frameworks for community care. • Preventative Models of Care – Urgent Community Response: an integrated Health and Social care approach, including Frailty and ASP - further development of community early response initiatives to prevent crisis escalation and emergency admissions. It is our vision that this addition to our community model will operate in a space between community escalation, GP OOH referral and community hospitals. Further, we would see this area of work as being linked with our roll out of the ‘’virtual ward’’ and our redefinition of community A&E models (namely to include extended assessment/same day emergency care/Ambulatory care as a sub tier of our existing A&A model. • Redesign of Urgent Care: redefinition of A&E model to include Ambulatory Urgent Care/Same Day emergency Care. This work includes consolidation of external pathways and partnership working with partners across Scotland. • Redefinition of Community Beds: in depth analysis of current use and proposals around re shaping inpatient model and resource, including staffing and location. • Intermediate Care – Stepping up and Stepping Down: development of alternative care settings to community inpatient models, enabling people to avoid admission or be discharged appropriately from an acute hospital. Taken together, these measures are intended to prevent admissions where possible and, where someone is admitted to hospital, ensure that the system ‘pulls’ them out with the support that is best matched to enable their recovery, facilitate reablement and maximise independence according to their preferences and levels of need. • Revised Approach to Discharge Coordination: Building on the integrated discharge plan. • Discharge to Assess (D2A): begins as soon as (or in some cases before) a patient is admitted to hospital and are then moved out of the acute environment whilst their individual needs are fully assessed at the earliest opportunity/avoiding delay. • Digital First and Virtual Care Management, Including Virtual Ward. • Care at Home – Organisational Redesign – Incorporating SDS Options. Our Guiding Principles and Enablers for Change - Integrated care with a Reablement Ethos and Approach – Maximising Independence: In 2012 the Scottish Government published ‘Maximising Recovery, Promoting Independence – a National Framework for Intermediate Care in Scotland.’ The National Framework sets out an approach involving a collection of services
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7 working to common to improve system flow, with shared objectives and principles. Intermediate care and reablement are described as a set of opportunities or ‘bridges’ at key points of transition in a person’s care journey; in particular from hospital to home (and from home to hospital) and from illness or injury to recovery and regaining independence in as timely a way as possible. The above high-level approach remains relevant to our context in Argyll and Bute. It is noted that there are two distinct strands of work required in order to effectively embed a Partnership wide reablement approach: Reablement Ethos and Reablement Service Delivery. On this basis, we are presenting a re-defined which suggests the following as an enabler for system change: Reablement Ethos – to enable, re-enable and promote independence at every opportunity, as early as possible: The ethos describes a shared approach across the Partnership for all service users, which has a focus on maximising outcomes and independence for the service user and reducing the need for/long-term dependence on services and resources. The ethos and principles of reablement would become the normal way of working across all services including Health, Social Care, Housing and external providers. This would include a preventative element, routing people at the earliest opportunity to services which better meet their needs, to prevent deterioration of their condition (Including non-statutory services and preventative programmes such as the Living Well Programme). As more service users are directed early, to a range of services, from a wide range of providers, it is hoped that fewer would require assessment for statutory services. This approach would also involve reablement as an ‘’opt out’’ rather than an ‘’opt in’’ for discharge planning, whereby all patients are screened for reablement potential and only cases where it is clear there would be no benefit of intervention would be ‘’opted out’’. The ethos would also acknowledge that reablement works most effectively as a timely intervention and as a shared responsibility across all teams. It is also noted that reablement may be accessed at other points in the care journey (i.e. not only in cases of escalation or discharge, but as the result of review and change in need). Reablement Service Delivery - The Reablement service/journey will begin at the point of assessment and have a focus on independence through the delivery of a short-term person-centred approach by a multidisciplinary team of well- trained staff working with patients, carers and their families. The reablement approach would be offered following an assessment against agreed criteria. This could be, for example, the frailty assessment or the social care adult assessment. Reablement in the Community - A key focus for the Integrated Plan (2024) is Discharge to Assess. This is intended to a) address issues supporting people’s timely discharge home from hospital, and b) ensure that assessment and care management planning/delivery is taking place in an optimum setting, within an MDT approach. This model will require rethinking of existing care models and revisiting of resources from core services (e.g. OT, social work and home care) and from integrated community care models (currently, broadly known as Extended Community Care Teams). Workforce Development - The landscape for our community health and social care, and social work service delivery needs to undergo a significant transformation, from specialist and/or condition-centred care toward value-based, generalist, people-centred models of care. The development and implementation
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8 of our plan is centred around our aim to re-imagine and transform service composition and delivery models in response to the challenges presented by ageing populations with multiple chronic conditions and complex care needs as well as the changing expectations of patients, their carers’, and communities. Throughout the life of the current plan (and beyond) community services will need to be underpinned by a resilient, resourceful and sustainable health and social care workforce (who are not only equipped with profession-specific knowledge and skills but will also possess the flexible qualities and generic approaches that will help them to work safely and sustainably in a changing, complex situations with limited available resource). In response to this objective, we propose a comprehensive assessment of the type of universal (core) skills that are required by our workforce to support patients to receive care in the right place, at the right time. These universal skills (also referred to as “soft” or “core” skills) and generalist ethos are the cornerstones for development of integrated models of care, delivered by a sustainable and flexible workforce, that is equipped to deliver both profession specific and generalist care – recognising shared roles, responsibilities and competences within inter-professional working. To achieve this vision, we propose the development of a common competency framework across multiple categories of health and social care delivery which could be used to foster collaboration across professional groups and encourage the development of multi-disciplinary care teams with shared skills, roles and responsibilities and ethos. Moving from Best Practice to Common Practice - Our approach acknowledges that the majority of new care models are designed to relieve pressures on the acute sector but have also been shown to have an impact on different parts of the health and social care system. It is important to acknowledge that for many of the areas of work specified, we are not starting from the beginning; there are many examples of best practice, effective working currently in operation across the HSCP, and as part of our overall transformational goals we would seek to evaluate and implement these in conjunction with (or as the foundations for) any new models that are proposed A common issue with many of the new care models being introduced across the HSCP is a lack of evidence about their impact, implementation costs; efficiency gains/cash savings, and outcomes for service users. As part of all developments proposed within this paper, we will aim to include these elements of measure. Given the financial pressures we face, it is important to monitor any new models to assess the impact on local systems and assess the costs, savings, outcomes and sustainability. This will help to assess the value for money of new models, whether the benefits justify the costs and if they should be rolled out more widely. 4. RELEVANT DATA AND INDICATORS • Integrated Management Performance Framework HSCP Reporting. • National Health and Wellbeing Indicators, Scottish Government. • Improvement Trajectories, Centre for Sustainable Delivery (CfSD). 5. CONTRIBUTION TO STRATEGIC PRIORITIES • Older Adult Strategy (Argyll and Bute HSCP).
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9 • Joint Strategic Plan (Argyll and Bute HSCP). • National Mission to Reduce Delayed Discharge (CRAG). 6. GOVERNANCE IMPLICATIONS 6.1 Financial Impact Redesign needs to find ways to provide services to older adults within a sustainable financial footing. 6.2 Staff Governance Staff Union Representatives have been included at the appropriate stage and will continue to be included should any conversation as to Organisational Redesign arise, per policy. 6.3 Clinical and Care Governance • None noted at this stage. 7 PROFESSIONAL ADVISORY • Professional Leadership from all services/disciplines has been included in the development and ongoing oversight/implementation of this plan. 8 EQUALITY & DIVERSITY IMPLICATIONS Older people are disproportionate users of urgent and unscheduled, health and wider social care services, therefore challenges for the delivery of these services may have a disproportionate impact on this group. 9. GENERAL DATA PROTECTION PRINCIPLES COMPLIANCE None noted at this stage. 10. RISK ASSESSMENT Continued pressure on staff resulting in issues with engagement and progress. The impact of recruitment and retention of staff across the health and social work and social care sector also results in unsustainable services with both Care Home and Care at Home capacity presenting significant challenge. Risks are being identified by senior responsible officers and managed by the System Pressures Group. Operational risks are identified and managed through local risk processes. 11. PUBLIC & USER INVOLVEMENT & ENGAGEMENT Engagement around this plan is encompassed within the wider engagement plan in relation the Older Adult Strategy. 12. CONCLUSIONS None noted. 13. DIRECTIONS Directions required to Council, NHS Board or both. Directions to: tick No Directions required x Argyll & Bute Council NHS Highland Health Board Argyll & Bute Council and NHS Highland Health Board
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10 14. PREVIOUS REVIEW OF THE REPORT Meeting Title of report Date Output (if relevant) REPORT AUTHOR AND CONTACTS: Caroline.Cherry@argyll-bute.gov.uk Karl.Mcleish@nhs.scot
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11 Stage of Process Where is the work being managed? Focus Actions Governance Community Standards Meeting structure, Assurance Framework and GGC interface • Meeting structure and assurance framework now revised (including locality management). To be implemented. • Emergency Admission (Scrutiny and Assurance). Crucially, this work should include a clear focus on readmissions within 28 days (and potentially a wider timescale). Avoidable admission to link with preventative work. Pre- Attendance/Avoidance of Admission A&E Delivery Group Review and Development of Business to Business Contracts – review of MDT/Decision making models at the front door and pathways of urgent care. • Review Models of Acute/Urgent Care - establish working group at pace. ToR to be established and clear objectives and timescales to be set. This work will inform the basis of NHS 24/FNC discussions to progress locality/regional model. • Business to Business Contract – Establish our current position and establish working group to establish integrated system approach to renewal which is responsive to models of care and meets requirements. Pre- Attendance/Avoidance of Admission Community Standards Power of Attorney/AWI - proactive promotion and management - links with frailty and prevention – recognition the PoA applies across the lifespan • Explore best practice/ innovation from neighbouring HSCP - considered the benefits of a business case to financially support POAs for those who reside in areas of deprivation. • Acceleration of Future Care Planning (FCP) work – Establish current position and ensure that there is a programme of work to include particular aspects, i.e. PoA, recognising PoA as an issue affecting the whole life-span. • Standard Operating Procedure to be reviewed with support from service manager for AWI/MHO. Agree via C&CG Include escalation process. Escalations to be taken forwards via the relevant Hos. Inc. SG escalations. Admission Avoidance/Alternative s to Admission TEC Steering Group Digital Transformation - Current TEC/Digital First Support for Discharge Without Delay • Link with planning and TEC leadership to establish current progress against transformation plan in this area. • Review TEC interface with assessment frameworks and role within Home First/D2A/Virtual Wards, etc. • Focus on virtual service delivery, where clinically appropriate, to support remote consultation and emergency assessment. Admission Avoidance/Alternative s to Admission Community Standards Care Homes and Housing Intermediate Care Models – H@H Models of Care – Home First and D2A • Comprehensive baseline assessment and associated action plan – Frailty Standards (SG). Links with Living Well/Prevention. • Intermediate Care - Overview Proposal to be drafted by end of August 2024 - Initial meetings held - consider in two phases. Phase 1 to consider a traditional approach to care home provision. Phase 2 to consider community offers of ''stepping care up'' and ''stepping care down''. Home first and discharge to assess as key areas (within H@H principles). Consideration of strategic use of LA estate and resource and focus on localities with pressure. • Formal Hospital at Home Pilot – review and next step. Hospital Pathways/Timely Disc harge Community Hospitals Community Standards Meaningful Activity and Reablement/Rehab/ECCT • Review of meaningful activity in inpatient settings to support early reablement and rehab and reduce pressure/LoS. • Clear definition/service specification and assessment/criteria for these services – Sub group commissioned to look at this work with particular focus on discharge approaches and promoting independence at an early stage. Hospital Pathways/Timely Disc harge Community Standards Post Hospital Assessment - Assessment process and resource. Timelines and Scrutiny – Discharge Process Audit. • Review national timescales (KPIs) for assessment. These are to be clarified (i.e. referral to assessment) and embedded. Collaboration with Planning and Performance/analysis of trend data on delays to explore barriers. Quantitative and qualitative review. • Undertake scoping with all areas. Propose standard suite of documents (ensuring link up with digital work). • Develop clear end to end integrated discharge policy. • Scope, define and implement discharge/flow navigation role as oversight and management for HSCP. Hospital Pathways/Timely Disc harge Inpatient Health and Safety Mental Health - What key areas are required to support MH/LD/Dementia admission avoidance and barrier to delay • Priority meetings with relevant leads to understand risks/current pressures and support needs (interface with Urgent Care). • Development of pathway for complex dementia (scope and define). • Development of training and development as generic skills for community staff/services to ensure safe/ timely discharge. Timely Discharge Care Homes and Housing Care Homes and Housing • Choice policy and local interpretation/delivery to be reviewed. Particular focus on realistic expectations and roles and responsibilities (Inc. management) Placement types to be revisited to accommodate intermediate care as developed. • Work required ensuring that system capacity (and reporting) is realistic and accurate (i.e. that vacant beds can be occupied, and vacancies are utilised in line with assessed need). Focussed collaborative work to address persistent staffing issues. • Continued focus on strategic assessment of need for future provision as a core part of the Older Adult Strategy. This work includes accommodation for key workers. Timely Discharge Care at Home Steering Group Community Standards Care at Home • Protocol for EoL Care Provision to be agreed and circulated –to ensure we support a patient in their place of choice (EoL). • Protocol – ongoing management of unmet need list (as dynamic a risk register, with MDT approach) to be developed. • Single point of referral and streamlined referral process is to be developed via Eclipse working group • Develop links so that providers are a core part of MDT/Discharge process. • Resource allocation work to progress (scheduling). to ensure resource is managed. • Continue to develop flexibly approaches to workforce (particularly remote and rural) to ensure sustainable provision. • Org redesign of the internal service and implementation of the new tender Post Discharge Social Work Priorities Review – Care Homes and Community – Managing Resources, Appropriate Care Delivery and Ensuring Sustainability. • Community - approach the work in 2 phases: Phase 1 - remedial - out of date reviews (from the post hospital or 6 month phase). Phase 2 - Business and Usual - lead professional model, with a clear oversight, governance and appropriate decision making bodies. Focus on releasing capacity and ensuring reablement potential is met/promoting independence. • Care Homes – Continue to embed model that has been developed and resourced in collaboration with wider MDT.